Complaints and Appeals
At Blue Cross and Blue Shield of Texas, we take pride in making sure you get the care you need. But if you have a complaint about how you are treated by your provider or your health plan, you can file a complaint. If you don’t like a decision we’ve made, you can file an appeal.
Understanding Complaints, Appeals and Benefit Decisions
What is a Complaint?
A complaint is not the same as an appeal. It can be about any matter besides a service that has been denied, reduced or ended. You can file a complaint to tell BCBSTX that you are unhappy with us or our operation. You have the right to give written comments, documents, or other information for your complaint. You can do this by calling or writing to us.
You may want to file a complaint if you have problems with:
- Access to health care services.
- Getting an appointment with your provider in a reasonable amount of time.
- The care or treatment you received.
You might also want to file a complaint if your provider or a BCBSTX employee:
- Did not respect your rights or was rude to you.
- Did not respect your cultural needs or other special needs.
- Did not provide an In-Lieu-Of Services (STAR and STAR Kids).
What is an Appeal?
You may not agree when BCBSTX decides to deny, delay, limit or stop a service. If you don’t agree, you can file an appeal. An appeal is a way for you to ask for someone to review our actions.
You might want to file an appeal if:
- BCBSTX does not pay for a service your PCP or other provider asked for.
- You did not get a service you wanted.
- You did not get an okay for services that your provider asked for.
- It is taking a long time to get the service you asked for.
- You had a service approved before, but now it is ending.
- BCBSTX did not approve a service because your provider was not in our network.
- BCBSTX did not answer your appeal in a timely manner.
How to File a Complaint or Appeal
There are different ways to file a complaint or an appeal. These can be related to health care or prescription drugs. Or they can be about service you received from BCBSTX. Check filing options for your plan.
To find out more about complaints and appeals, check the Member Handbook for your plan.
